Monday, 30 April 2012

ER "doctors"

If any of you have aspirations of becoming a doctor, I hope you've never watched any television shows or seen any movies that show emergency physicians in any positive light, because that may spur you into dreams of joining their ranks.  After all, they tend to get glamourised as the lifesavers, the quick thinkers, the saviors.


Want to know what they really do?  They torture real doctors like me.  Think that sounds arrogant?  Well think again and keep reading.

A young healthy man was brought to the emergency room by paramedics a few nights ago having been involved in a "car accident".  That's in quotation marks for a reason.  The paramedics didn't call him a "trauma" because there wasn't enough mechanism to cause any harm.  The triage nurse agreed that he didn't meet criteria to be a trauma patient, so he triaged him to the main emergency room to be seen by the emergency physician.  The ER doc overheard part of his story, and the only words he somehow heard were "drunk" and "unconscious".

"But a drunk, unconscious car accident victim should be seen by a trauma surgeon!" I hear you thinking.  And that's entirely true.  So what the hell is the problem here?

He was neither drunk nor unconscious.  Here's what actually happened:

At 4 AM this young man left his friend's house, got in his car, and promptly fell asleep.  The car was parked and he had not been drinking; he was just tired.  After falling asleep, another car "bumped" his car from behind while parking.  He felt the bump, called the police to report the accident, and then fell back asleep.  When the paramedics arrived, he was "unconscious", aka asleep.  I'm not sure where the ER doc heard that he was drunk, but this kid had suffered less trauma that night than I had.  But in his infinite wisdom and without even laying eyes on the patient, the emergency physician upgraded him to a trauma.  He apparently said that he was too busy to deal with another drunk guy.  I confronted him and asked for the reason for the upgrade, and he admitted that he hadn't seen him, he had just heard that he was drunk.  I tried to explain that he was not drunk, and he wasn't even injured.  He simply blew me off and tended to his other duties.

Lifesavers?  Quick thinkers?  How about time wasters and non-thinkers.

Saturday, 28 April 2012


When I was 13 years old, I got really angry at something and kicked a hole in the wall of my bedroom.  It was a perfect heel-sized hole exactly where my heel would land if I were to kick the wall.  When my parents found the hole, they asked me how it got there.

"I don't know," I replied.  "Bugs?"

No offense, but teenagers are dumb.

Holy shit, stop screaming at me!  I said "No offense!"  But seriously, teenagers are dumb.  Well, I suppose it's all relative.  Perhaps I shouldn't say dumb...I should probably say that you're just dumber than we adults.  The only reason I say this is because it's true, and because you prove it to me daily.

A 16 year old boy was brought to me just now having been shot in the right leg.  This isn't news around here - people get shot routinely - drug deals gone bad, robberies, gang violence, Little Red Riding Hood minding her own business walking through the forest delivering muffins to Grandma - and this kid was no different.  He said Some Dude (it's always Some Dude, his brother This Guy, or their sister Some Bitch) approached him and just started firing.  FIVE SHOTS he said he heard.

The problem is that there was a single gunshot wound on the front of his mid-thigh, and the bullet was sitting just in front of his kneecap.  I'll give you a minute to figure this one out.  Go ahead, put your right index finger in the middle of the front of your right thigh, and put your left middle finger over your right kneecap.  Did you figure out the problem with the story?  There is no way in hell that a bullet would have followed that trajectory had he been shot from the front.  However, if you stand up, make your right hand into a little gun, put it in your pants waistband, and pretend to pull the trigger, that just happens to put the bullet exactly in the right place.

He stuck by his story, even as the police hovered over him and questioned him.  While they were doing this, I made a small incision over his patella and extracted the bullet.  (If you're wondering why I removed it, it's because it would have bothered him for the rest of his life and it was very superficial.)  I felt like asking him if he really thought any of us believed him, but I realised it wouldn't make a bit of difference.

When he comes back to get his sutures out, I think I'll ask him again and see if he sticks to his guns.

No pun intended.

UPDATE (6/20/2012): He did come back about a week later to get the sutures out, and by golly he did stick to his story.  I just looked at him over my glasses in that "give me a break" way, and he just stared back in that "you won't break me" way.  Ugh...stupid kids.

Tuesday, 24 April 2012

Good choices

Not doing drugs: good choice
Wearing your seatbelt: another good choice
Not taking your prescribed diabetes medicine: bad choice
Running from bail bondsmen: worse choice
Running from bail bondsmen into high-speed traffic with sky-high blood sugar from not taking your prescribed diabetes medicine: REALLY bad choice

A 29-year old man had a warrant for his arrest, so when three bail bondsmen showed up at his door, he ran.  He didn't just run, he ran into traffic.  A car hit him at full speed, knocking him out, breaking two ribs, puncturing his lung, breaking his leg, and lacerating his liver.

The best part of this whole thing were the two police officers barking at him just before I put in a chest tube to re-expand his collapsed lung.  They were basically telling him the same thing I would have - next time a bail bondsman comes to your door to pick you up, make the right choice and just go with him.

Tuesday, 17 April 2012

It doesn't take a genius

It doesn't take that many brain cells to learn from one's mistakes.  I guess some people just don't have enough.  I know what you're thinking - "Everyone has enough brain cells, Doc!"  Ok, that may be true.  But some people just choose not to use the brain cells they have.

A guy was brought to me a few nights ago having been found down by police.  "Found down" can mean one of several things:
  • Pedestrian hit by a car
  • Had a heart attack or stroke
  • Really, really, really drunk
There are several other options of course, but what I've learned is that the third option is usually the right one.  Such was the case of the gentleman alluded to above.  He admitted to me that he drank about a liter and a half of liquor (that's about three pints) that night.  "How often do you do that?" I asked him.

"Whenever I can afford it, Doc."

Nice.  I like him already.

As the workup progressed, one of my assistants thought this drunken sot looked familiar.  She looked up his information, and sure enough he had been admitted to my hospital just 8 days prior having been in a car accident while piss drunk (yes, that's the official medical term).  His blood alcohol while he was driving was 320 (0.32, or about 4 times the legal limit).  I guess he figured he hadn't done well enough that time, because in spite of totaling his car a week before while drunk, he failed to learn a goddamned thing.

This night his blood alcohol was 380.

So what is it?  Had he been drowning his brain in booze for so long that the cells had decided to defect and now refuse to function properly anymore?  Or are some people actually that self-destructive?

Believe it or not, I'm actually glad when people get this drunk.  Wait, wait, stop screaming and keep reading.  There actually was one good thing about his being so inebriated - at least he was too drunk to get behind the wheel this time.

Wednesday, 11 April 2012

Ask the right question

When I graduated from medical school, my father (who was also a general surgeon) told me to listen to the patient, because 80% of the time the patient will tell you the diagnosis.  They may not come right out and say, "Doc, I have appendicitis," but if you read between the lines, patients' stories often speak louder than any CT scan or blood test.  However, you usually have to listen very closely and always ask the right questions.

I was consulted on a 41 year old man with severe anemia and what looked like bleeding into his abdomen on CT scan.  He was a pretty healthy guy, he took no medications, and he had no prior surgeries.

The reason I was called is because 99% of the time intra-abdominal bleeding is due to trauma.  I asked the man if he had been in a car accident recently - no.  Had he been kicked or punched in the abdomen?  Nope.  Fallen on his side?  No again.

Well, damn.  I looked at his CT scan, and sure enough it looked to me like he had a ruptured spleen.  I searched my brain for any other reason for him to have a ruptured spleen.

Bicycle accident?  Any violent coughing or sneezing fits?  Grizzly bear attack?  ANYTHING?  No, no, and no.  I obviously wasn't asking the right question.  Regardless, he was bleeding to death internally and needed surgery.  I took him to the operating theatre and removed his spleen that looked like this:

After surgery, I decided I had to do some investigating.  I had to know why this man's spleen popped.  He admitted to lightly "bumping" his abdomen against a concrete bird feeder earlier that morning as he was trying to move it, but a simple little bump shouldn't cause the spleen to burst.  Unless it was enlarged.  Enlarged...wait just a second!  I suddenly had a hunch.  Maybe I just hadn't asked the right questions yet...

I asked him if he'd been feeling very fatigued lately, and he said he had.  I asked him if he had a terrible sore throat recently, and he said he had.  Any fevers?  Yes indeed.  He started looking at me strangely. "What does my cold have to do with my spleen, Doc?"

This was no ordinary cold.  His monospot test confirmed that he had infectious mononucleosis, also called "mono".  Mono can cause the spleen to become quite enlarged, and his had enlarged so much that his little "bump" was enough to cause it to rupture.

His postoperative course was uneventful, and he went home a few days later.  "How did you figure that out?" he asked me just before he left.  I just smiled but didn't answer him - it just wasn't the right question.

Thursday, 5 April 2012


I regularly see patients who take a laundry list of medications.  For people who have high blood pressure, diabetes, gout, arthritis, high cholesterol, atrial fibrillation, depression, seizures, and anxiety, I can understand not being able to remember the names and dosages of all 20 of their medications.  But those people better damned well have a printed and laminated list of all of them that they carry around with them wherever they go.  I've seen these lists a few times, and I almost feel like it's a minor miracle.  I've almost hugged a few patients for carrying around their medication menu.

But if you take two or three medications, how difficult is it to remember them?

A patient this morning told me, "I take a little blue one for my heart.  And a round white one for my sugar."

What are they called, sir?

"Hell, I can't remember the names."

Of course you can't.  "Do you remember the dosages at least?"  I asked, thinking I may be able to extrapolate to some of the more common ones.  "Or would you at least recognise the names if I said them?"

"Nope, don't think so, Doc.  Oh, I think one of them starts with a 'p'.  Does that help?"

Seriously?  These are drugs which are prolonging, saving, or otherwise improving your life, and you can't even remember them?  I've talked before about knowing your body, and of all the surgeries I've had (hernia repairs, appendectomy), I can tell you the name of the surgeon and when and where they were done.  That's called being a responsible adult.

Not knowing what you take makes it that much more difficult to take care of you, and it drives me absolutely bonkers when people don't know their own medical or surgical history.  I can feel my blood pressure rising just thinking about this crap.

Oops - it must be time to take my medicine.  Now if only I could remember which one...

Monday, 2 April 2012

Drug or not a drug?

Marijuana is a drug.  That should be the end of this post because it seems this should be intuitively obvious to even the feeblest of intellects.  Now I will concede that marijuana may be less harmful than cigarettes, and it is certainly less harmful than alcohol.  You can die of alcohol poisoning, but it's essentially impossible to die of a marijuana overdose.  And I will definitely concede that THC has several benefits for certain people, including stimulating the appetite and decreasing nausea in cancer patients and decreasing intraocular pressure in glaucoma patients.

However, this isn't about the danger of marijuana, this is simply about the stupid argument made by stupid people that marijuana is an herb, not a drug.  Or that it's a leaf, not a drug.  This always seems to be the argument of the A) uninformed or B) pothead.

Let me get this straight - What you're claiming is if it comes from a plant then it can't be a drug?  Interesting.

So I guess aspirin isn't a drug because the salicylic acid was discovered in a willow tree. I suppose taxols, a class of chemotherapy, aren't drugs because they were isolated from the Pacific Yew tree, and vinblastine and vincristine (more chemotherapy drugs) also aren't drugs because they come from the Madagascar periwinkle. Digoxin (a heart medication) can't possibly be a drug because it was discovered in the foxglove plant. And caffeine CERTAINLY can't be a drug because it's found in tea leaves and coffee beans.

Let's not even start with how cocaine can't be a drug because it's extracted from the coca leaf!  And damn it, heroin can't be a drug because it comes from the opium poppy. Hell, that's a FLOWER! How the hell can it be a drug, right?  RIGHT??

I have to assume these idiots are just stoned when saying this.  I welcome any and all comments from potheads, I mean marijuana advocates supporting their theory.  Oh and by the way, trying to claim that my analogies are invalid because the poppy is "processed" to get the opium out is ridiculous - you "process" the marijuana by burning it before inhaling the fumes.

Ready to argue?  And...go!